Spinal Cord Infarction Following Therapeutic Computed Tomography-Guided Left L2 Nerve Root Injection

Abstract

We report the fourth case of spinal cord infarction following nerve root injection. The severity of this complication warrants that it should be considered during patient consent for this procedure.

Extraforaminal needle tip position reduces risk of intravascular injection in CT-fluoroscopic lumbar transforaminal epidural steroid injections

“…There are 19 case reports of spinal cord injury following conventional fluoroscopic-or CT-guided thoracolumbar TFESI (3,4,6,8,16,(23)(24)(25)(26)(27)(28)(29) [(although the complication is known to be underreported due to its medicolegal implications (8)]. Review of the imaging and procedural descriptions for these 19 case reports shows a foraminal needle location, sometimes deep within the neural foramen, in 7 of these cases; in the remaining 12, insufficient information is provided to determine needle depth relative to the targeted neural foramen (3,29).…”

“…Quincke-tipped spinal needles (BD Medical, Franklin Lakes, New Jersey) of a variety of calibers (25,23, and 22 gauge) and lengths [3.5 inch (90 mm), 5 inch (130 mm), and 7 inch (180 mm)] were utilized for the procedures. Using intermittent CT-fluoroscopic guidance, needles were positioned at or near the posterior aspect of the neural foramen.…”

Particulate versus non-particulate steroids for lumbar transforaminal or interlaminar epidural steroid injections: an update

“…In the literature, all 17 thoracolumbar spinal cord infarctions related to lumbosacral epidural steroid injection were associated with particulate steroids whereas no case of paraplegia was described after image-guided epidural injection of dexamethasone [16][17][18][19][20][21][22][23][24][25][26]. It has to be noted that the damage to the spinal cord commonly occurred several segments cranial to the lumbosacral injection site: for instance, in the case reported by Chang Chien et al, a transforaminal epidural steroid injection was performed at the level L5-S1, but subsequently spinal cord infarction on MRI was diagnosed between the T6 and the T9-T10 level [25].…”

“…All except for one [24] thoracolumbosacral spinal injection associated with ischemic complications described above were carried out as image-guided interventions, either by fluoroscopy or CT, and the use of complementary contrast agent application before steroid injection was common. Spinal cord injury occurred in 11 patients after fluoroscopy-guided [16, 18, 20-23, 25, 26] and in four patients after CT-guided lumbar epidural steroid injections [16,19,21]. Even the combination of negative blood and cerebrospinal fluid aspiration with digital subtraction angiography (in order to exclude intravascular or intrathecal contrast medium spread) seems not to reliably exclude spinal cord infarction associated with lumbar transforaminal epidural steroid injection at the level of L5-S1 [25].…”

“…Death as well as infarction of cerebellum, brain stem, thalamus, cervical, and lumbar spinal cord have been reported after cervical and lumbar epidural injections, either by an interlaminar or transforaminal approach [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. In the literature, all 17 thoracolumbar spinal cord infarctions related to lumbosacral epidural steroid injection were associated with particulate steroids whereas no case of paraplegia was described after image-guided epidural injection of dexamethasone [16][17][18][19][20][21][22][23][24][25][26].…”